Evidence-Based Practice & Transformational Leadership Change Model

Transformational leadership may be defined as an innovation as it is not in wide or general practice across the medical and healthcare fields. An innovation must, by definition be characterized by benefits that are accrued only through adoption of the innovation into practice or general use. Transformational leadership has been shown to have benefits for patients and patient care, as well as for those practice transformational leadership in their work, and the colleagues that are directly impacted by these transformational leaders. Because of the benefits that accrue to those who practice transformational leadership, it is anticipated that the attrition of nurses may be ameliorated by a diffusion of transformational leadership into the practice.

Diffusion of innovation theory. A variety of change models have been employed to describe the introduction and adoption of innovations in professional practice. The diffusion of innovation theory, a change model developed by Everett Rogers, is particularly well suited as a framework for introducing innovation into a clinical or hospital setting. Rogers posited that the diffusion of an innovation takes place over four distinct stages: The actual invention or introduction of an innovation, diffusion through communication across a social network or system, the passage of time, and the consequences or outcomes that follow introduction and/or adoption of the innovation. The step-wise proposed solution of introducing a leadership-oriented program for high level nurses addresses the stages of diffusion that are anticipated as the training plan is implemented.

At the core of the diffusion of innovation theory is a construct that certain conditions can increase or decrease the likelihood that an innovation will be adopted. The following influential conditions have been considered for the proposed solution: Roles of adopters in the social system, the attributes of the innovation itself, the modes of communication used in the social network, the complexity of the decisions to be made about the innovation, and the attributes of the social context.

The transformational leadership training plan will be implemented through a series of steps as outlined below. Each description of the training programs steps also includes a discussion of the ways in which the change model applies to the particular stage and how outcomes are measured in each stage according to the tenets of the change model.

Environmental assessment. An environmental scan or assessment will help to identify sources of negativity that can undermine the change effort if they are not addressed or at least brought out into the open. Eliminating all forms of negativity in the environment is not a rationale expectation. But Roger's diffusion of innovation theory points to certain attributes of the social context, the decision-process, and the communication styles used that can be modified to condition the environment for change. The persons trying to introduce the innovation should target their communications about the innovation -- or underlying problems that may act as barriers to diffusion of the innovation -- to people who have a "professional resemblance" to them (Sanson-Fisher, 2004). As much as possible, communication should be face-to-face as this allows messages about the innovation to be shaped to fit the receptivity and answer any looming or persistent questions. This first step in the training process corresponds with the first stage in the decision process, which is essentially awareness of the innovation. The second stage in the decision process is when others are encouraged to consider the advantages and benefits of the innovation they are expected to adopt. Discussion about the second stage and third stages follow below.

Training plan implementation. The head nurses will receive training in transformational leadership. Steps two and three of the decision process are addressed in this stage of the training plan. That is, the nurses are encouraged to learn about the benefits of becoming skilled transformational leaders, and the nurses become engaged in activities that establish a basis for deciding if they are willing to adopt the innovation. Two congruent and simultaneous change initiatives are being implemented in the context of the medical center. Transformational leadership is an innovation at SLVAMC, as is evidence-based practice. The one innovation -- transformational leadership -- will be employed to condition the environment and develop the nursing staff so that they may more fully and readily adopt the other innovation -- evidence-based practice. It is here, in the second stage of the training process and the third step of the decision process, that the characteristics of the innovation come deeply into play.

A central tenant of the diffusion of innovation theory is that the attributes of a new or substitute behavior substantively impact whether it will be adopted. These attributes are: 1) Relative advantage of...

The majority of attributes of the social context of a healthcare facility are not conducive to the diffusion of innovation. Healthcare facilities are hierarchical, have professional unit silos, and have cultures that tend not to be creative. One attribute of the social context of a healthcare facility that can be used to encourage innovation is strong leadership (Sanson-Fisher, 2004). Transformational leadership can be utilized to ensure that evidence-based practice is introduced at SLVAMC. And transformational leadership can go a long way towards reducing barriers to diffusion of the innovation by tackling the bureaucratic tendencies and social norms that work against easy adoption of innovative practice (Sanson-Fisher, 2004).
Role of adopters in social system. Rogers saw three roles in a social network or system as having influence on the course of diffusion of innovations: Opinion influencers, change agents, and gatekeepers. In the clinical or hospital setting, the opinion influencers will tend to be higher level nurses who have already had training for transformation leadership, or those who are eager to engage in such training.

For all members of a social system undergoing exposure to innovation, five levels of acceptance and adoption of the innovation are seen. In order of temporal adoption, these categories are: 1) innovators, 2) early adopters, 3) early majority, 4) late majority, and 5) laggards. Adoption by users is known to assume an S-shaped curve in the early stages and smooth into a bell-shaped curve as the innovation ages. The proposed solution will measure the progress of users toward adoption through surveys and strategy planning meetings.

The relative advantage of transformational leadership in the nursing profession is a highly subjective dynamic. Prior research indicates that transformational leadership that has positive outcomes for nurses who have received the training and apply the leadership skills in their practice. Transformational leadership is highly compatible with the high standards for patient outcomes and professional expectations of nurses. It is expected to lead to greater overall job satisfaction and more thoughtful, rational patient care. Leadership skills are very teachable and with practice, mentoring, and a receptive environment, most nurses are likely to find that they can draw directly from the training in ways that enhance both their praxis and their status. Essentially, transformational leadership is inherently trialable with each nurse learning and putting into practice skills sets in a step-wise fashion. Last, the training program is designed to ensure appropriate visibility of the transformational leadership initiative.

Section F: Implementation Plan

Setting and subjects. Higher level management nurses at the hospital will receive training in transformation leadership. Management approval for the training and the use of facilities will be obtained. The project participants will be selected from volunteers and through observation of nurses who exhibit interest in practice changes like evidence-based practice (EBP) and otherwise appear to welcome change in their professional lives.

Project timeline. The training plan will be implemented over the course of a year. Transfer of training assessments will occur on a quarterly basis, following completion of training modules. Once training facilities have been reserved, a week-by-week timeline will be finalized.

Project resources. The training will be provided by in-house nurses who have had leadership training and who have some teaching experience. Presumably, these will be nurses who have earned a Masters degree. The hospital is equipped with several classrooms and these will be scheduled in advance for the seminars and modules.

Methods and instruments. The Leadership Practices Inventory (LPI) will be used to assess the transfer of training into praxis. Surveys developed explicitly for the research will undergo pilot-testing. The purpose of the surveys will be to establish the participants' knowledge about transformational leadership as it is implemented in clinical and hospital settings, about EBP, and about organizational change.

Delivery process and training. Training will be provided to volunteer assistants who will code interview responses and input survey data into Excel for cross-tabs analysis. In addition, inter-coder reliability will be used to assess the reliability of the…